Altercare of Navarre: Lab Test Lost for 9 Days - OH
The resident, identified in inspection records only as Resident 90, has lived with quadriplegia, a suprapubic catheter, neurogenic bladder dysfunction, and a personal history of recurring urinary tract infections. He also carries a diagnosis of extended spectrum beta lactamase, a bacterial infection known for its resistance to common antibiotics, which makes identifying the right treatment through culture and sensitivity testing especially important.
On the evening of May 19, 2026, nurses documented that he was sweating heavily, his blood pressure was elevated, and his catheter was draining urine that was cloudy and foul-smelling. Urology was contacted and a nurse practitioner ordered blood work. The next morning, urology called back with instructions: change the suprapubic catheter, collect a urine specimen for culture, fax the results to urology, and start him on minocycline 100 milligrams twice daily for seven days.
A physician's order was written that same day, May 20, to collect the urine and send it out for a culture.
By early afternoon, staff had changed the catheter and collected the specimen. A progress note recorded that the sample was placed in the specimen refrigerator.
That was the last documented step.
No culture results appear anywhere in the medical record between May 20 and May 29. Nine days after the specimen was collected, inspectors arrived at the facility on a complaint investigation. That morning, the Corporate Director of Nursing told inspectors she had never received any results from the laboratory. She said she had called the lab that same day, May 29, and the laboratory had no record of the specimen ever being picked up.
The specimen was collected. An order existed. A refrigerator received it. Nobody confirmed it left.
Resident 90's medical profile makes the gap more than a paperwork problem. His diagnoses fill nearly a paragraph: quadriplegia, chronic respiratory failure, neurogenic bowel, hydronephrosis with ureteral stricture, cachexia, polyneuropathy, hypotension, diabetes, seizures, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome, among others. He had intact cognition, meaning he was aware of what was happening to him and to his body. He was already on an antibiotic when the culture was ordered, but the point of the culture was to confirm whether that antibiotic was the right one, and whether the bacteria causing his infection was susceptible to it.
That confirmation never came.
Inspectors rated the violation at the minimal harm level, a designation that reflects the regulatory finding at the time of inspection rather than what the resident experienced across those nine days. The inspection was conducted as a complaint investigation, complaint number 2998973, and only three residents were reviewed for bowel and bladder concerns. Resident 90 was the one with the problem. The facility census was 91 residents.
The inspection report does not say whether Resident 90's condition improved or worsened during the nine-day window. It does not say whether his responsible party, who had been notified of the original orders, was told that the specimen never reached the lab. It does not say whether a new specimen was collected after May 29.
What it says is that urology ordered a test, a physician ordered a test, a nurse collected the specimen and put it in a refrigerator, and then nothing happened for nine days until an inspector asked about it.
The Corporate Director of Nursing confirmed all of it on the morning of May 29, after making a phone call she apparently had not made before that day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare of Navarre Ctr For Rehab & Nrsg Care from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ALTERCARE OF NAVARRE CTR FOR REHAB & NRSG CARE in NAVARRE, OH was cited for violations during a health inspection on May 29, 2026.
Urology was contacted and a nurse practitioner ordered blood work.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.